Sunday, July 11, 2010

The End of "Rescue Medicine"

Like many others, I am still reeling from the "recess appointment" of Dr. Donald Berwick as the new Director of the Center for Medicare and Medicaid Services (CMS). But unlike others who feel his appointment was a "sneeky move," I would have to admit that it was brilliant political display of "The Chicago Way."

You see in Chicago, if you hold a position of great stature politically, you don't have to ask permission from anyone to do things. You just do them.

Don't like an airport and want it closed? Just call The Boys and have them go out and rip up its runway under the cover of darkness. You just have to have some forward-looking perspective: like a cool $1.4 million a year in revenues that can be gained from the amphitheatre The Boys build there.

Problem handled.

When things like this happen here, people kick and scream and fuss and fume, but they're ultimately left powerless to do anything about it, so they just take some money and move on.

And so it is likely to be with medicine.

For quite a while.

Oh sure, we can all kick and scream and fuss and fume, but it would be far better for us understand what we've really just gained.

It is not just the shift from "rescue care" to the philosophy of a "redistribution of wealth" as Mr. Berwick has espoused earlier:

"You could have protected the wealthy and the well, instead of recognizing that sick people tend to be poorer and that poor people tend to be sicker, and that any healthcare funding plan that is just, equitable, civilized and humane must -- must -- redistribute wealth from the richer among us to the poorer and less fortunate," Berwick said in a 2008 speech in London on the virtues of the British healthcare system. "Excellent healthcare is by definition redistribution. Britain, you chose well."

No, it is far more sinister.

My concern is that rather than achieving a overt means of health care rationing vetted by the populous, the covert nature of health care rationing will continue via administrative fiat. As such, people and large health care institutions will continue to be given their government payments to "play nice" by the many, many new "rules," or else. In effect, our health care system has the potential to evolve into a macabre reenactment of bloated, bureaucratic system that defines "The Chicago Way."

After all, since Mr. Berwick won't insist on his own appointment be publicly vetted before our elected representatives, what will that mean for the health care decisions that come from his office and costs of the bureaucracy behind it all?

26 comments:

The dumbing down of health care will be quite a crises I think. Part of the problem is the way the government subsidizes the working ill until they become the non-working ill. Then things go down hill faster.

I wouldn't be so pessimistic. The odds are looking very good the GOP will take back both the House and Senate this fall. And, if that happens, I'd lay down even money that some very pissed-off congressmen are quickly going to give Dr. Berwick a political colonscopy he won't soon forget.

The Meigs story is a little more complex.... It was Chicago Park District land (owned by the taxpayers of Chicago.) It was a single runway that was used primarily by state legislators (those guys who also had some "political stature") and those who had private planes. Oh dear, now those poor disenfranchised folks have to go to Midway or O'Hare just like the rest of us citizens! Yes, Daley wanted it shut down and eventually did "in the dark of night", but a state, city, and fed compromise had been worked out to keep the airfield open for twenty-five years. The US Senate (in 2001 and therefore Republican) refused the federal portion of the deal. Daley plowed the runway in 2003. Meigs field is now a lovely PUBLIC park with a public beach where ALL Chicagoans can enjoy a lovely summer's day on THEIR land paid for by their taxes. Damn! It sure was a miserable way to treat the poor downtrodden private plane owners. I don't know about the amphitheater. But if it is anything like the Grant Park bandshell, we need a half dozen more!

But, to get back to the Dr's recess appointment. Do you really think he would have been able to avoid a filibuster in the Senate? Hell, Jonas Salk would be filibustered. But dont fret. Soon the power will shift and we'll have folks like Sharon Angle making appointments to Medicare. Now that should prove very interesting. If she gets her way, I'd guess that there will be fewer AF ablations.

The first paragraph was seriously strange and inane all at once: 'The recess appointment of Don Berwick to lead CMS can be seen as a cynical act of political opportunism, sidestepping the Congressional approval process using a tactic worthy of Machiavelli, or Karl Rove. Or it can be viewed as a pragmatic decision by Obama to avoid a lengthy and exasperating re-litigation of the healthcare reform debate'...

How much damage can Dr. Berwick do in the half a year+ he has before the recess appointment ends. I predict he will destroy the administrative and organizational structure of Medicare and Medicaid, promote a lot of fellow travelers (after all, he is a Communist), and funnel about $5 Billion dollars down untraceable ratholes. After all, Dr. Berwick is an honorable man.

The most dangerous people in the world are people such as Dr. Berwick. They are otherwise intelligent people, but they are so ideologically driven that they actively maintain a willful ignorance that will forever shield them from the knowledge of the destruction their actions cause. They are so certain they are right, they fell no need for research or debate, and they convince themselves that the half-truths they reiterate are the final word. I honestly believe that Dr. Berwick believes in what he is doing and would consider himself on of the good guys. But the kind of mindset he has cultivated is the same mindset that throughout history has allowed otherwise good people to do monstrous things.

In the video posted at the top of the post, Berwick quotes statistics about American healcare without revealing his sources. In essence, he asks us to believe his "studies" with nothing more than an appeal to his own authority. The type of studies he is referencing are notoriously unreliable, such as WHO studies that put Cuban healthcare above the US. Dr. Wes talks about infant mortality, or overall mortality, which are often distorted statistic, since we are dependent on the veracity of totalitarian governments when we compare such statistics with those of the US. He doesn't site the studies and he doesn't site the countries he believes to be better in mortality than the US. In essence, he leaves the listener with no way to learn for himself what he is talking about, only an unspoken, "trust me, I'm an expert."

The health care landscape consists of too many special interest groups to allow the types of governance by public fiat that you suggest. Every disease and entity of health care delivery has its own lobby to protect their interests. Witness the recent controversy over Provenge for prostate cancer where there were actually threats against members of the FDA Advisory group who voted against approval of the drug for use for prostate cancer, despite its' rather mediocre effect.

The problem with this current approach is it does not take into account the overall costs to the health care system and our serious need to reign in these costs. We will need to prioritize what we can afford and what we cannot. We cannot continue to pay for medications that cost tens of thousands of dollars and extend life for four months. Our dollars are better off spent elsewhere quite frankly.

Rationing is the big dirty word here, but we all know that rationing takes place. The only debate is how this rationing will occur; will it be through the current system of access to insurance which equates to economic rationing, or do we take a more sensible approach of identifying those treaments that are most cost effective and eliminating those that are of marginal benefit.

I would suggest to you that this would still not deny patients access to these marginally effective treatments, since patients can still opt to pay for them out of pocket. They could also consider opting for those more expensive plans (like the boys at Goldman Sachs have) to cover every potential need their providers recommend. Under the new health care law, they will simply have to pay the additional tax on such a policy.

You have seemingly fallen for this idea that goverment is intruding with a heavy hand in the lives of its citizens that is propagated by the Republican party as part of its campaign to regain seats in congress. But I fail to see this in practice to date. All of this talk of a goverment takeover is just that with no evidence to back it up. The example you use for Dr. Berwick, who is an acknowledged expert in this field, is once again imagining the worse without clear evidence of such a sinister goal. How about giving this change a chance before you become so critical? Does not the president deserve to put the people in charge that he wants to enact this new health care plan? Blocking his appointment is just part of the same tactics of denyng and delaying that have been the substance of the Republican party agenda for the past 2 years. One gets the impression that they are hoping an praying that Obama will fail.

Surely as a past-60 white male, I belong to a class over-represented in the patient population. Accordingly, when I need heart surgery, I suspect I will go to the end of the line until a requisite number of members of under-represented classes get elective surgery. Given budget constraints, that requisite number is unlikely ever to be reached.

Surely as a past-60 white male, I belong to a class over-represented in the patient population. Accordingly, when I need heart surgery, I suspect I will go to the end of the line until a requisite number of members of under-represented classes get elective surgery. Given budget constraints, that requisite number is unlikely ever to be reached.

RE: "How about giving this change a chance before you become so critical?"

How about using facts and historical examples as our guide to find out how healthcare "reform" is going to turn out?

In 1993 Tennessee tried healthcare reform modeled after Hillarycare. It decimated the healthcare industry in the state with high costs that led to reduced payments that led to physicians and insurance companies leaving the state.

In Massachusetts they are following the same path as Tennessee. Costs have gone up as coverage is expanded. Insurers are denied the ability to raise premiums to cover the increased costs. Soon we will see insurers and providers leave the state just as in Tennessee.

Maine's experiment in government healthcare did not fare so well, either. Nor did Oregon's. Both have cut benefits to try and deal with the rising costs.

How about other countries? Canada is trying to save their system by increasing privitazation of some services. Great Britain's NHS has chronic problems with low-quality care, long waiting lists, and higher mortality rates for diseases like breast and prostrate cancer than the US.

History shows that government run healthcare is littered with failure. Why should we go down that road also? We should turn around now before it is too late.

Just as Dr. Wes must be pleased when his blog generates lots of comments, I want you to know that I give a sigh of relief when you sign on. These comments were so disheartening - we're even getting down to the level of "fellow traveler".

So just ask I thank Dr. Wes for taking the time to write this often provocative blog, I thank you for taking the time to provide some much needed opposition.

Kim-Jung il is a military enemy of the US and any hostile actions towards Americans would have probable cause for a military response.

bin Laden's actions have already had a military response and follow up criminal responses.

Dr. Berwick, on the other hand, has the force of American law behind him, and the death sentences he hands out - all for the best of reasons of social justice, they will assure you - are enforceable by the FBI, the IRS, the DOJ, etc.

Ah, yes, recess appointments. Never used by George W. Bush, just by "Chicago" politicians, eh?

"Ideologically driven" - another term that of course could not be applied to Bush and cronies, or the even more frightening Sarah Palin and Sharon Angle. Only "librulls" are "ideologically driven", the rest are just plain brilliant.

Give me the British system any day, rather than the inflated, wasteful system we have. I could write a book, or at least a very long magazine article, about the unnecessary testing to which I have been subjected in the name of "the best health care in the world", ending up with one result: fattening the pockets of the doctors who ordered the testing, the facilities that carried them out, and yes, the insurance companies who use the "high cost of great care" to justify ridiculous premiums.

Yes, we are back to the "good old days". Anyone who is not right-wing enough is labelled a Communist. Can blacklisting be far behind?

Keith said"You have seemingly fallen for this idea that goverment is intruding with a heavy hand in the lives of its citizens that is propagated by the Republican party as part of its campaign to regain seats in congress. But I fail to see this in practice to date. All of this talk of a goverment takeover is just that with no evidence to back it up."

Hmmm. You simultaneously say you see no evidence of intrusion to date, while suggesting it's premature to judge.

Obama has said in the past that the direction he wants to go is a gradual process. That is what we are witnessing.I have personal experience with a cardiologist telling me he was already under pressure to ration in regards to my father and a pacer/defib. As we move towards a "Medicare for all" scenario, resources will be further stretched, providers will begin to bail and quality will suffer.Oh...just my conspiracy seeking nature. But high level recess appointments don't tend to dissuade one from those.

Here's the crux of the problem: We will need to prioritize what we can afford and what we cannot. We cannot continue to pay for medications that cost tens of thousands of dollars and extend life for four months. Our dollars are better off spent elsewhere quite frankly.

WE need to do no such thing because WE are (or should not be) paying for anything.

YOU make YOUR decisions.I shall make MY decisions.

There is no "we".

If YOU believe YOUR dollars are better spent elsewhere, fine. YOU don't have to buy prostate cancer drugs with a mediocre affects. If I think "mediocre" is better than "nothing", who are you to decide whether there is a better use for MY money?

"Give me the British system any day, rather than the inflated, wasteful system we have. I could write a book, or at least a very long magazine article, about the unnecessary testing to which I have been subjected in the name of "the best health care in the world", ending up with one result: fattening the pockets of the doctors who ordered the testing, the facilities that carried them out, and yes, the insurance companies who use the "high cost of great care" to justify ridiculous premiums. "

Were you chained down and forced to undergo these tests? And if the tests were "unnecessary", what prompted them in the first place? Surely an army of doctors did not break down your door and "subject" you to testing. And if one of these fat cats had missed a debilitating or even fatal condition, would you have cheerily gone to your grave or would you have sued his or her pants off?

What drives health care cost is DEMAND. Patients have sniffles and "pain" and this and that, and they DEMAND answers. That leads to tests and tests lead to therapies. Patients do not want to take responsibility for their health or the costs that they incur.

As far as the covert nature of things medical goes, there is nothing like state psychiatry as a demonstration of the direction things are going.

Ulysses S. Grant said there's no better method to secure the repeal of bad or obnoxious laws than their stringent enforcement. A corollary might be that there's no better method to prevent repeal of bad or obnoxious laws than their careful obfuscation.

At every psych ward I know of, when they coerce a patient to sign himself or herself in "voluntarily", the form is presented as a "five-day release".

There's something very odd about a comment here. We are talking about a profession whose first credo is do no harm. A profession whose goal is to help others. A profession that deals with our blood, our shit, our cancers, our flabby and blocked hearts, our sick children. I bet not one of those folks, doctor, nurse, tech, has EVER said, "there is no we". Thank god

I know you guys can think about the future. After all, many are screaming about deficits and their grandchildren. But on the other hand we don't fix bridges until they fall down, oil wells until they start gushing, and sewers when they start blowing up. My brother is screaming about his future water bill increase due to the EPA. I have read and read and read again about communists, cabals, takeovers, trials, and the big bad wolf. Can't we have a small smattering of your idea of how to make it better? I'm pretty sure most don't think the present system is sustainable. And you do think about those grandchildren. So guys, give us some ideas - other than returning the same guys to power who have not done anything to sustain our health care for the last 50 years. You need not worry about the guy who can do it himself - who finds that there is no "we".

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.